Differences in medical services in Nordic general practice: a comparative survey from the QUALICOPC study

Objective: We aim to describe medical services provided by Nordic general practitioners (GPs), and to explore possible differences between the countries.

Design and setting: We did a comparative analysis of selected data from the Nordic part of the study Quality and Costs of Primary Care in Europe (QUALICOPC).

Subjects: A total of 875 Nordic GPs (198 Norwegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answered identical questionnaires regarding their practices.

Main outcome measures: The GPs indicated which equipment they used in practice, which procedures that were carried out, and to what extent they were involved in treatment/follow-up of a selection of diagnoses.

Results: The Danish GPs performed minor surgical procedures significantly less frequent than GPs in all other countries, although they inserted IUDs significantly more often than GPs in Iceland, Sweden and Finland. Finnish GPs performed a majority of the medical procedures more frequently than GPs in the other countries. The GPs in Iceland reported involvement in a more narrow selection of conditions than the GPs in the other countries. The Finnish GPs had more advanced technical equipment than GPs in all other Nordic countries.

Conclusions: GPs in all Nordic countries are well equipped and offer a wide range of medical services, yet with a substantial variation between countries. There was no clear pattern of GPs in one country doing consistently more procedures, having consistently more equipment and treating a larger diversity of medical conditions than GPs in the other countries. However, structural factors seemed to affect the services offered.     

Harm caused by adverse events in primary care: a clinical observational study

Rationale, aims and objectives  Patient safety in primary care is important, but not well studied. The aim of our study was to determine the actual and potential harm caused by adverse events in primary care.
Method  Observational study in two general practices, including the patients of five doctors. Two methods were used to identify adverse events; (1) a prospective registration of adverse events by the general practitioner and (2) a retrospective audit of medical records. Actual harm was registered and a clinical analysis was made to estimate potential harm.
Results  A total of 31 adverse events were collected and analysed. The adverse events were spread over different adverse event categories. About half of the events did not have health consequences, but a third led to worsening of symptoms and a few resulted in unplanned hospital admission. Potential negative health consequences were likely in three-quarters of the events.
Conclusions  The identified adverse events had some impact on health outcomes, but a risk for harm existed in a majority of the events. Patient safety programmes in primary care should focus on adverse events and not just on harm.     

Association between continuity of care in Swedish primary care and emergency services utilisation: a population-based cross-sectional study

Objective: The primary objective of this study was to determine the association between longitudinal continuity of care (CoC) in Swedish primary care (PC) and emergency services (ES) utilisation.

Study design: A cross-sectional analysis of longitudinal population data. Setting. PC centres, out-of-hours PC facilities and emergency departments (EDs) in Blekinge County in southern Sweden. Subjects: People of all ages who lived in Blekinge County and who had made two or more visits per year to a general practitioner (GP) during office hours from 1 January 2012 to 31 December 2014.

Main outcome measure: ES utilisation.

Results: Eight-thousand one-hundred and eighty-five people were included in the study. CoC was quantified using three different indices—Usual Provider of Care index (UPC), Continuity of Care index (CoCI), and Sequential Continuity index (SECON). The CoC that the PC centres could offer their enrolled patients varied significantly between the different centres, ranging from 0.23–0.57 for UPC, 0.12–0.43 for CoCI, and 0.25–0.52 for SECON. Association between the three CoC indices and ES utilisation was computed as an incidence rate ratio which ranged between 0.50 and 0.59.

Conclusion: Longitudinal CoC was shown to have a negative association with ES utilisation. The association was significant and of a magnitude that implies clinical relevance. Computed incidence rate ratios suggest that patients with the lowest CoC had twice as many ES visits compared to patients with the highest CoC.     

Trends in the perceived complexity of primary health care: a secondary analysis

Rationale If the complexity of the patient's medical problems increases or the complexity of the interactions between the doctor and the patient, the staff or the health care system increase, then complexity of patient care will increase. This study examined trends in patient complexity, and identified doctor, practice and improvement strategy characteristics associated with perceived complexity. Methods This secondary analysis used data from three Community Tracking Surveys with 22 134 primary care doctors completing surveys about themselves, their practice setting, practice improvement strategies and complexity of care in three consecutive 2‐year time periods (1996–1997, 1998–1999, 2000–2001). Data were analysed using hierarchical logistic regression. Results The proportion of primary care doctors who perceived that complexity of care had increased over the past 2 years rose from 31.5% to 35.9%. Perceived complexity of patient care was consistently related to being in solo practice and the belief that they could not frequently obtain high‐quality services and referrals for patients. As availability of services increased, complexity decreased whereas as use of practice improvement strategies increased, complexity also increased. Conclusions Understanding that we cannot determine whether respondents understood care as ‘complicated’ or ‘complex’, potential consequences of this increase in complexity include an increase in medical errors and referral rates along with decreased quality of patient care and career satisfaction.     

Use of a Web-based clinical decision support system to improve abdominal aortic aneurysm screening in a primary care practice

Rationale, aims and objectives The United States Preventive Services Task Force recommends a one‐time screening for abdominal aortic aneurysm (AAA) with ultrasonography for men aged 65 to 75 years who have ever smoked. However, despite a mortality rate of up to 80% for ruptured AAAs, providers order the screening for a minority of patients. We sought to determine the effect of a Web‐based point‐of‐care clinical decision support system on AAA screening rates in a primary care practice. Methods We conducted a retrospective review of medical records of male patients aged 65 to 75 years who were seen at any of our practice sites in 2007 and 2008, before and after implementation of the clinical decision support system. Results Overall screening rates were 31.36% in 2007 and 44.09% in 2008 (P‐value: <0.001). Of patients who had not had AAA screening prior to the visit, 3.22% completed the screening after the visit in 2007, compared with 18.24% in 2008 when the clinical support system was implemented, 5.36 times improvement (P‐value: <0.001). Conclusions A Web‐based clinical decision support for primary care physicians significantly improved delivery of AAA screening of eligible patients. Carefully developed clinical decision support systems can optimize care delivery, ensuring that important preventive services are delivered to eligible patients.     

Quality of chronic kidney disease management in primary care: a retrospective study

Background: Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. Aim: To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. Design and setting: Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). Method: CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. Results: Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. Conclusion: Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model.

• Key points

• Quality of care for chronic kidney disease patients in primary care can be improved.

• In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic kidney disease patients.

• Quality of care was higher in patients with diabetes.

• Chronic kidney disease management may be improved by developing strategies similar to diabetes care.

     

The impact of specialist care for low back pain on health service utilization in primary care patients: A prospective cohort study

Guidelines portray low back pain (LBP) as a benign self‐limiting disease which should be managed mainly by primary care physicians. For the German health care system we analyze which factors are associated with receiving specialist care and how this affects treatment. This is a longitudinal prospective cohort study. General practitioners recruited consecutive adult patients presenting with LBP. Data on physical function, on depression, and on utilization of health services were collected at the first consultation and at follow‐up telephone interviews for a period of 12 months. Logistic regression models were calculated to investigate predictors for specialist consultations and use of specific health care services. Large proportions (57%) of the 1342 patients were seeking additional specialist care. Although patients receiving specialist care had more often chronic LBP and a positive depression score, the association was weak. A total of 623 (46%) patients received some form of imaging, 654 (49%) physiotherapy and 417 (31%) massage. Consulting a specialist remained the strongest predictor for imaging and therapeutic interventions while disease‐related and socio‐demographic factors were less important. Our results suggest that the high use of specialist care in Germany is due to the absence of a functioning primary care gate keeping system for patient selection. The high dependence of health care service utilization on providers rather than clinical factors indicates an unsystematic and probably inadequate management of LBP.     

Measuring perceptions of safety climate in primary care: a cross‐sectional study

Rationale, aims and objectives Building a strong and positive safety culture in health care teams and organizations is essential for patient safety. Measuring individual perceptions of safety climate is an integral part of this process. Evidence of the successful application and potential usefulness of this approach is increasingly available for secondary care settings but little is known about the safety climate in UK primary care. We therefore aimed to measure perceptions of safety climate in primary care. Further aims were to determine whether perceptions varied significantly between practice teams and according to specific participant and practice characteristics. Method We undertook a cross‐sectional, anonymous postal questionnaire survey of randomly selected west of Scotland primary care teams. Safety climate mean scores with standard deviations were calculated for respondents, practice teams and the region. Results A total of 563 (84%) team members from 49 practices (24.5%) returned questionnaires. The overall safety climate mean score was 5.48 (0.78). Significant differences in safety climate perceptions were found at the practice team level (P < 0.001) and for specific characteristics: respondents' years of experience, whether they were community or practice based, their professional roles and practices' training status. Practice managers and general practitioners perceived the safety climate more positive than other respondents (P < 0.001). Conclusion This was the first known attempt to measure perceptions of safety climate in UK primary care with a validated instrument specifically developed for that purpose. Reported perceptions of the prevailing safety climate were generally positive. This may reflect ongoing efforts to build a strong safety culture in primary care or alternatively point to an overestimation of the effectiveness of local safety systems. The significant variation in perception between certain staff groups has potential safety implications and may have to be aligned for a positive and strong safety culture to be built. While safety climate measurement has various benefits at the individual, practice team and regional level, further research of its association with specific safety outcomes is required.     

From resistance to rescue – patients’ shifting attitudes to antihypertensives: A qualitative study

Abstract

Objective. The objective of this study was to gain a deeper knowledge and understanding of experiences of antihypertensive drug treatment. Design. Interview study. Setting. A primary health care centre in western Sweden. Method. Qualitative interviews and analyses through systematic text condensation described by Malterud. Subjects. Ten informants in pharmacological treatment for high blood pressure (six men and four women). Main outcome measure. Experiences of hypertension drug treatment. Results. The findings revealed a process starting with resistance to drug treatment related to lack of control, side effects, and unwanted awareness of impaired health. These negative feelings then changed into a positive desire for lifestyle changes caused by a fear of cardiovascular disease which in turn changed the attitude towards drugs into seeing them as a rescue remedy and something normal and this then evoked health care trust. Conclusion. Despite initial resistance to treatment, the experience of antihypertensive drug treatment became more positive with time. Confidence in the health care system is important for adherence to treatment. General practitioners have a key role in this regard.     

Patient and provider perspectives on reducing risk of harm in primary health care: a qualitative questionnaire study in Sweden

Abstract

Objective: To explore how patients, that had experienced harm in primary care, and how primary providers and practice managers understood reasons for harm and possibilities to reduce risk of harm.

Design: Inductive qualitative analysis of structured questionnaires with free text answers.

Setting: Primary health care in Sweden.

Patients/subjects: Patients (n?=?22) who had experienced preventable harm in primary health care, and primary care providers and practice managers, including 15 physicians, 20 nurses and 24 practice managers.

Main outcome measures: Categories and overarching themes from the qualitative analysis.

Results: The three categories identified as important for safety were continuity of care, communication and competence. With flaws in these, risks were thought to be greater and if these were strengthened the risks could be reduced. The overarching theme for the patient was the experience of being neglected, like not having been properly examined. The overarching theme for primary care providers and practice managers was lack of continuity of care.

Conclusion: Primary care providers, practice managers and patients understood the risks and how to reduce the risks of patient safety problems as related to three main categories: continuity of care, communication and competence. Future work towards a safer primary health care could therefore benefit from focusing on these areas.

• Key points

• Current awareness:

• ??Patients and primary care providers are rather untapped sources of knowledge regarding patient safety in primary health care.

• Main statements:

• ??Patients understood the risk of harm as stemming from that they were not properly examined.

• ??Primary care providers understood the risk of harm to a great extent as stemming from poor continuity of care.

• ??Patients, primary care providers and practice managers believed continuity, communication and competence play an important role in reducing risks.

     

The significance of a collaborative practice model in delivering care to chronically ill patients: A case study of managing diabetes mellitus in a primary health care center

Non-communicable diseases, especially diabetes mellitus type two (DM2) constitute major health problems in Lebanon that have an adverse impact on health and health resources. Collaborative practice interventions may improve quality care of DM2 and reduce or delay complications. The purpose of this paper was to evaluate the impact of collaborative practice on the quality and cost of effective care for diabetic patients in a primary health care center. A chart audit review of 375 diabetic patients attending an inner city health center in Beirut (Lebanon) was conducted after three and a half years of collaborative practice intervention, which included guidelines for an interdisciplinary health team. Evaluation of the impact of collaborative practice was conducted on the process and outcome of care. The results indicated a high level of enthusiasm, support and the development of team spirit at the process level. At the outcome level there was improvement in documentation, increase in patient recruitment, increase in continuity of care, improvement of glycemic control and decreased cost. In conclusion collaborative practice interventions improved process and outcome variables for diabetic patients. It is suggested that this model could be developed for use in the care of other chronic diseases.     

Impact of staffing levels and resources of intensive care units on compliance to standard mechanical ventilator guidelines: A city-wide study in times of COVID-19 pandemic

Background

The COVID-19 pandemic has affected millions and resulted in a considerable strain on healthcare systems around the world. Intensive care units (ICUs) are reported to be affected the most because significant percentage of ICU patients requires respiratory support through mechanical ventilation (MV).

Aim

This study aims to examine the staffing levels and compliance with a ventilator care bundle in a single city in Pakistan.

Methods

A cross-sectional survey of 14 ICUs including medical and surgical ICUs was conducted through a self-structured questionnaire including a standardized ventilator care bundle. We assessed the compliance of ICU staff to ventilator care bundle and calculated the correlation between staffing patterns with compliance to this bundle.

Results

The unit response rate was 64% (7/11 hospitals). Across these seven hospitals, there were 14 functional ICUs (7 surgical and 7 medical). The Mean (SD) numbers of beds and ventilators were 8.14 (3.39) and 5.78 (3.68) while the average patient-to-nurse and patient-to-doctor ratio was 3: 1 and 5:1 respectively. The median ventilator care bundle compliance score was 26 (IQR = 21–28) out of 30, while in medical and surgical ICUs, median scores were 24 (IQR = 19–26) and 28 (IQR = 23–30) respectively. The perceived least compliant component was head elevation in ventilated patients. Correlation analysis revealed that 24 h a day, 7 days a week onsite cover of Advanced Cardiovascular Life Support certified staff was positively correlated with the ventilator care bundle score (r_s = 0.654, p value = .011). Similarly, 24-h cover of senior ICU nurses was significantly correlated with the application of chlorhexidine oral care (r_s = 0.676, p value = .008) while routine subglottic aspiration was correlated with the number of doctors (r_s = 0.636, p value = .014).

Conclusion

Our study suggests that ICUs in Peshawar are not well staffed in comparison with international standards and the compliance of ICUs with the ventilator care bundle is suboptimal. We found only a few aspects of ventilator care bundle compliance were related to nursing and medical staffing levels.

Relevance to clinical practice

Critical care staffs at most of the medical ICUs in Peshawar are not compliant with the standard guidelines for patients on mechanical ventilation. Moreover, the staffing levels at these ICUs are not in accordance with international standards. However, this study suggests that staffing levels may not be the only cause of non-compliance with standard mechanical ventilator guidelines. There is an urgent need to design and implement a program that can enhance and monitor the quality of nursing care provided to mechanically ventilated patients. Lastly, nurse staffing of ICUs in Pakistan must be increased to enable high quality care and more doctors should be trained in critical care.     

Integrated care models in Swiss primary care: An embedded multiple case study

Rationale, Aimsand Objectives

Healthcare systems are confronted with a rising number of patients with chronic conditions and complex care needs, requiring the development of new models of coordinated, patient-centred care. In this study, we aimed to describe and compare a range of new models of care recently implemented in primary care in Switzerland, as well as to gain insight into the type of coordination or integration implemented, the strengths and weaknesses of each model and the challenges they face.

Method

We used an embedded multiple case study design to describe in-depth a series of current Swiss initiatives that specifically aim to improve care coordination in primary care. For each model, documents were collected, a questionnaire was administered and semistructured interviews with key actors were conducted. A within-case analysis followed by a cross-case analysis were performed. Based on the Rainbow Model of Integrated Care framework, similarities and differences between the models were highlighted.

Results

Eight integrated care initiatives were included in the analysis, representing three types of models: independent multiprofessional GP practices, multiprofessional GP practices/health centres that are part of larger groups and regional integrated delivery systems. Recognized effective activities and tools to improve care coordination, such as multidisciplinary teams, case manager involvement, use of electronic medical records, patient education and use of care plans, were implemented by at least six of the eight initiatives studied. The main obstacles to the implementation of integrated care models were the inadequate Swiss reimbursement policies and payment mechanisms and the desire of some healthcare professionals to protect their territory in a context where new roles are emerging.

Conclusion

The integrated care models implemented in Switzerland are promising; nevertheless, financial and legal reforms must be introduced to promote integrated care in practice.     

Individual care plans for chronically ill patients within primary care in the Netherlands: Dissemination and associations with patient characteristics and patient-perceived quality of care

Objective. To examine the use of individual care plans (ICPs) within primary chronic illness care in the Netherlands, and to explore the relationships between ICP use, patient characteristics, and patient-perceived quality of care. Design. Cross-sectional study using survey data from a panel of chronically ill patients and medical registration data provided by their general practices. Setting and subjects. A sample of 1377 patients with somatic chronic disease(s) randomly selected in general practices throughout the Netherlands, supplemented with a sample of 225 COPD patients, also recruited from general practices. Main outcome measures. (i) Percentage of ICP use based on self-report by chronically ill patients, and (ii) patient-perceived quality of care as assessed using the Patient Assessment of Chronic Illness Care (PACIC). Results. ICP use among the total generic sample was low (9%), but slightly higher (13%) among patients diagnosed with diabetes or COPD, diseases for which disease management programmes have been set up in the Netherlands. Patients with a low educational level and patients with poor(er) self-rated health were more likely to have an ICP. Compared with patients without an ICP, patients with an ICP more often reported that the care they received was patient-centred, proactive, planned, and included collaborative goal setting, problem-solving, and follow-up support. Conclusion and implications. Findings reveal a discrepancy between practice and policy aspirations regarding ICP use in primary chronic illness care. More research is needed to gain insight into the effectiveness of ICPs to improve the quality of chronic illness care in various patient populations.